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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 493004746
Report Date: 05/31/2024
Date Signed: 05/31/2024 05:52:32 PM

Document Has Been Signed on 05/31/2024 05:52 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME:KELLEY, WENDY FAMILY CHILD CARE HOMEFACILITY NUMBER:
493004746
ADMINISTRATOR/
DIRECTOR:
KELLEY, WENDYFACILITY TYPE:
810
ADDRESS:TELEPHONE:
(707) 539-7524
CITY:SANTA ROSASTATE: CAZIP CODE:
95409
CAPACITY: 14TOTAL ENROLLED CHILDREN: 14CENSUS: 11DATE:
05/31/2024
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:32 PM
MET WITH:Wendy KelleyTIME VISIT/
INSPECTION COMPLETED:
05:59 PM
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A Required Annual inspection was made to the facility by Licensing Program Analyst (LPA), Robert Maciel. A review of staff records on 5/30/2024 indicates that all facility staff or other individuals who require caregiver background checks received a criminal record and child abuse index clearances or exemptions. Licensee was reminded that all adults 18 and over living or working in the home, including employees and volunteers, except as specified in Health and Safety Code section 1596.871, must obtain a criminal record clearance or exemption, or transfer their existing clearance or exemption, prior to initial presence in a licensed Family Child Care Home. A civil penalty of $100.00 minimum/day for a maximum of 5 days or, if the penalty is for a repeat violation, for a maximum of 30 days per person will be assessed if this regulation is violated.

During today’s inspection the home and grounds were toured. The Licensee was supervising 11 children and was operating within the licensed capacity and ratio requirements. No children were observed left in any parked vehicles. The facility’s operating hours are 7:30 AM to 5:00 PM, Mon–Fri. The floor plan submitted by the licensee was reviewed and verified. The children will have access to the main backyard, the play room, the kitchen, and the nap room. The "off limits" areas include the home's master bedroom, master bathroom, bedrooms 1, and 2, the hallway bathroom, the front yard, and the backyard behind the master bedroom. These areas were made inaccessible by doorknob slipcovers and baby gates. The home was at a comfortable indoor temperature. The children in care have access to age-appropriate toys and equipment. There is a working telephone in the home. Licensee’s pediatric CPR/First Aid certification was current and expires in March 2026. Items which could pose a danger to children (detergents, cleaning compounds, medications, etc.) were stored out of the reach of children. There is a functional smoke detector, carbon monoxide detector and a fully charged fire extinguisher rated at least 2A10BC. The licensee stated that poisons, firearms, and ammunition are not stored on the premises and none were observed by the LPA.


Continue to LIC 809-C.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE: DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/31/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KELLEY, WENDY FAMILY CHILD CARE HOME
FACILITY NUMBER: 493004746
VISIT DATE: 05/31/2024
NARRATIVE
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The regulation that poisons are to be locked using a key or combination lock was reviewed. The backyard is fully fenced. The backyard is separated by a fence which divides it into two spaces. The main space contains play structures and toys for children. The separate space is only accessible through the master bedroom back exit. There is a hot tub in the backyard in the fenced area behind the master bedroom which is locked. The Licensee did not record an emergency disaster drill within the last six months. The facility roster of the children in care was reviewed and did not reflect the children currently enrolled. LPA reviewed staff and personnel records at 3:13 PM which contained all records as required. LPA reviewed five children's records (C1-C5) at 2:53 PM which revealed that child 1,2, and 4's (C1, C2, and C4) immunizations were not recorded on the PM 286 immunization record form.

LPA discussed the safe sleep regulations with licensee and discussed the Child Care Licensing Safe Sleep webpage at https://www.cdss.ca.gov/inforesources/child-care-licensing/public-information-and-resources/safe-sleep as an additional resource. LPA also informed licensee of the importance of checking for recalled infant devices on the United States Consumer Product Safety Commission (CPSC) website at https://www.cpsc.gov/ and recommended they register all infant devices with the CPSC to be notified of any recalls on their purchased equipment.

Incidental Medical Services (IMS) policy was discussed. For IMS information see PIN 22-02-CCP. When any IMS is provided, a Plan for Providing IMS must be submitted to the Department. The following information regarding ADA was provided: US Department of Justice (USDOJ) toll-free ADA Information Line at (800) 514-0301 (voice)/ (800) 514-0383 (TTY) and link to publication: Commonly Asked Questions about Child Care Centers and the ADA, available at: https://www.ada.gov/resources/child-care-centers/.
Continue to LIC 809-C.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SANTA ROSA RO, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405
FACILITY NAME: KELLEY, WENDY FAMILY CHILD CARE HOME
FACILITY NUMBER: 493004746
VISIT DATE: 05/31/2024
NARRATIVE
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On this date, 05/30/2024, the California Attorney General - Megan’s Law website was searched for information on sex offenders required to register with local law enforcement under California's Megan's Law. No registered sex offenders were found at the facility address. Under state law, some registered sex offenders are not subject to public disclosure; therefore, they may not have been included in this search. However, the Department conducts a monthly cross reference of each address on record for all registered sex offenders against all CCLD facility addresses pursuant to information shared by California DOJ. During the exit interview, the Licensee Wendy Kelley, confirmed that there are no Registered Sex Offenders living in the facility and LPA completed the RSO profile in FAS.

Licensee was informed of the MyChildCarePlan.org website; a consumer education website that helps families obtain childcare by connecting them to child care providers and Resource and Referral Agencies (R&Rs) throughout California.

To improve the quality and value of the new inspection process, a survey may be sent to the email address provided. Please complete the survey and share your inspection experience. If you have any questions regarding the process or CARE tools, please send email inquiries to inspectionprocess@dss.ca.gov. For additional information regarding the inspection and its tools and methods, please visit the Program website at www.cdss.ca.gov/inforesources/community-care-licensing/inspection-process.



The following violation(s) of the California Code of Regulations, Title 22; Division 12, were observed: see LIC 809D. Appeal Rights were provided. Exit interview conducted and report was reviewed with Licensee Wendy Kelley. A notice of site visit was given and must remain posted for 30 days. Failure to comply with posting requirements shall result in an immediate civil penalty of $100.
SUPERVISORS NAME: Alexis Hollon
LICENSING EVALUATOR NAME: Robert Maciel
LICENSING EVALUATOR SIGNATURE:

DATE: 05/31/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/31/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 05/31/2024 05:52 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/31/2024 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KELLEY, WENDY FAMILY CHILD CARE HOME

FACILITY NUMBER: 493004746

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102417(g)(9)(A)1
Operation of A Family Child Care Home
(g) The home shall be free from defects or conditions which might endanger a child. Safety precautions shall include but not limited to: (9) Each family child care home shall have a written disaster plan of action prepared on a form approved by the Department. All children, age and ability permitting, and the provider, the assistant provider, and other members of the household, shall be instructed in their duties under the disaster plan. As their age and ability permit, newly enrolled children shall be informed promptly of their duties as required in the plan. (A) Each family child care home shall conduct fire drills and disaster drills at least once every six months. 1. The licensee shall document the drills, including the date and time of each drill. This documentation shall kept at the family child care home.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on record review, the licensee did not record a disaster drill within the last six months which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
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4
Licensee stated that she would conduct a disaster drill, record it onto the disaster drill log, and send a copy to LPA by email at robert.maciel@dss.ca.gov.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 05/31/2024 05:52 PM - It Cannot Be Edited


Created By: Robert Maciel On 05/31/2024 at 04:29 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1450 NEOTOMAS AVENUE, STE. 100
SANTA ROSA, CA 95405

FACILITY NAME: KELLEY, WENDY FAMILY CHILD CARE HOME

FACILITY NUMBER: 493004746

DEFICIENCY INFORMATION FOR THIS PAGE:

VISIT DATE: 05/31/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
102418(g)
Immunizations
(g) The licensee shall document each child's immunizations as required by the California Code of Regulations, Title 17, Section 6070, and shall maintain such documentation for as long as the child is enrolled.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review, C1, C2, and C4's immunizations were not recorded on the PM 286 immunization record form which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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Licensee stated she would document each child's immunizations on the PM 286 form and send a copy to LPA by email at robert.maciel@dss.ca.gov.
Type B
Section Cited
CCR
102417(g)(8)
Operation of A Family Child Care Home
(8) Each family child care home shall have a current roster of children as specified in Health and Safety Code Section 1596.841.

This requirement is not met as evidenced by:
Deficient Practice Statement
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2
3
4
Based on observation, the facility roster of children in care did not reflect the children currently enrolled which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/14/2024
Plan of Correction
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2
3
4
Licensee stated she would update the facility roster and send a copy to the LPA by email at robert.maciel@dss.ca.gov.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Alexis Hollon
LICENSING EVALUATOR NAME:Robert Maciel
LICENSING EVALUATOR SIGNATURE:
DATE: 05/31/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/31/2024


LIC809 (FAS) - (06/04)
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